Awake intubation under light sedation with Remimazolam and remifentanil in a patient with trismus following maxillary gingival Cancer surgery: A case report

Awake tracheal intubation is an option during general anesthesia induction in trismus patients, although the method often causes discomfort and distress for the patient. Remimazolam, a new short-acting benzodiazepine drug, is reportedly useful in this situation, because it provides appropriate sedation and rapid recovery while maintaining spontaneous respiration. We report nasotracheal intubation under sedation with remimazolam and remifentanil in a patient with trismus, without any particular discomfort. The patient was a woman in her 80s who had developed trismus following maxillary gingival cancer surgery three years earlier, who currently required breast cancer surgery. Preoperative examination revealed a restricted mouth opening of only one finger width. Anticipating difficulty in laryngoscope insertion and difficult intubation, we decided to perform nasal intubation under light sedation with remimazolam, with additional fentanyl and remifentanil for sedation and prevention of discomfort during intubation. This strategy allowed maintenance of spontaneous respiration and successful intubation with no hemodynamic instability. Trismus is a critical airway scenario with limited backup options, making preservation of spontaneous breathing essential. In such cases, remimazolam is useful for sedation-assisted intubation, since it offers precise titration, causes minimal respiratory and circulatory depression, and has a wide safety margin, along with the availability of antagonists. Our experience suggests that tracheal intubation under mild sedation with remimazolam and remifentanil might be useful in patients with trismus.